A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?

Choice A reason: Cheyne-Stokes respirations, alternating hyperventilation and apnea, indicate neurological dysfunction or end-of-life changes in brain tumor patients, not pain. This reflects brainstem involvement, requiring respiratory management rather than analgesics, as it is a physiological response to disease progression in palliative care.
Choice B reason: Mottled skin signals poor perfusion or impending death, common in palliative care as circulation declines. It is not a pain indicator but a sign of systemic shutdown, requiring comfort measures like warmth, not analgesics, which are irrelevant to this physiological change in terminal illness.
Choice C reason: Constricted pupils may reflect opioid effects or neurological changes in brain tumor patients but do not directly indicate pain. They suggest autonomic or brainstem dysfunction, necessitating neurological assessment, not immediate pain medication, in palliative care where comfort is prioritized based on clear pain cues.
Choice D reason: Grimacing indicates pain in palliative care patients with brain tumors, reflecting physical discomfort. As a facial expression of distress, it signals the need for analgesics to improve comfort and quality of life, aligning with palliative goals to manage pain effectively in end-stage disease.

Choice A reason: Advancing the walker and taking a step towards it is the correct technique, ensuring stability by moving the walker first, then stepping. This maintains balance and prevents falls, aligning with safe walker use protocols, so no intervention is needed for this action.
Choice B reason: Taking multiple steps while holding the walker compromises stability, as the walker must be repositioned after each step to ensure support. This increases fall risk, requiring the charge nurse to intervene to correct the technique and ensure the client’s safety during ambulation.
Choice C reason: Grasping the walker by the hand grips on the upper bars is correct, as it provides optimal control and balance. This standard technique supports safe mobility, and no intervention is required, as it adheres to proper walker use guidelines.
Choice D reason: Lifting the walker as it is moved forward is acceptable for lightweight or rolling walkers, depending on the client’s strength and model. While sliding is preferred for standard walkers, lifting is not inherently unsafe, so intervention is unnecessary unless improper execution is observed.